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Introduction to How Lobotomies Work

It's evening in a mental hospital in Oregon, and there's a struggle happening between a noncompliant patient and the head nurse. Because of the violent patient's actions, the head nurse has him committed to a special ward for patients deemed "disturbed." He also undergoes a lobotomy -- an operation in which the connections between the frontal lobes and rest of the brain are severed. The procedure leaves him in a vegetative state. Upon his return to the ward, another patient, Chief Bromden, remarks that "There's nothin' in the face. Just like one of those store dummies." This scene, from the novel One Flew Over the Cuckoo's Nest and the subsequent film, was the first time that many people ever heard of a lobotomy. For some, it's still the first thing that comes to mind: an operation on the brain that makes a violent, noncompliant patient calm or even completely unresponsive. In the late 1950s, when Ken Kesey wrote his book, lobotomies were used to treat many different types of mental illnesses, including anxiety, depression and schizophrenia. The procedure was also performed on people who were considered extremely emotional, difficult to handle or simply "moody." With the wide range of drugs and other types of therapies available to treat severe mental illness today, it's hard to imagine that doctors once thought that such a drastic operation was the way to a cure. As you'll read in this article, it wasn't always much of a cure. Let's start by looking at exactly what goes into performing a lobotomy. The lobotomy is a type of neurosurgery, or surgery performed on the brain, known as psychosurgery. The idea behind psychosurgery is that severe forms of mental illness can be treated by changing the way that the brain works. Doctors believed that by severing the connections that the frontal lobes, or prefrontal cortex, had to the rest of the brain, they could calm patients' emotions and stabilize their personalities without doing away with their intelligence and motor functions. The prefrontal cortex serves a number of complex functions in the brain, usually called executive functions. (Higher-level decision making and planning, reasoning and understanding, personality expression, creativity and behaving in a socially acceptable way all fit under this category.) The prefrontal cortex is connected to many other regions of the brain, including the thalamus, which receives and relays sensory signals. The brain is essentially composed of two different types of matter: gray and white. Gray matter includes the neurons, or brain cells, along with their blood vessels and extensions. White matter comprises the axons, or nerve fibers, that connect the areas of gray matter and carry messages between them through electrical impulses. So a lobotomy was intended to sever the white matter between different areas of gray matter. (Another name for lobotomy, leucotomy, means "slice/cut white" in Greek.) The first lobotomies were performed in 1935 by Portuguese neurologists Dr. Antonio Egas Moniz and Dr. Almeida Lima. Initially, they drilled holes in the skull on either side of the prefrontal cortex and injected the connecting fibers with alcohol to destroy them. However, this procedure resulted in too many complications, including damage to other parts of the brain.
Moniz then decided to use a tool called a leucotome. After drilling holes in the skull, the doctor pressed on the back of the tool, which extended a wire or metal loop inside. By extending and then retracting the leucotome, he could remove cores of white matter. In 1936, a neurologist and psychiatrist named Dr. Walter Freeman and his partner, Dr. James Watts, began performing lobotomies in the United States. Ten years later, Freeman perfected a new method. Moniz's technique, called a prefrontal lobotomy, required a patient to go under general anesthesia in an operating room. Freeman wanted to find a technique that was faster, more accessible and less expensive, so he decided to get to the prefrontal cortex through the eye sockets instead. Freeman first practiced on cadavers using an ice pick, which is how his method came to be known as the "ice pick lobotomy." When he began performing the transorbital lobotomy on patients, he used a stronger version of a leucotome that resembled an ice pick, called an orbitoclast. After going through the top of the eye socket, Freeman could enter the brain just by tapping lightly on the orbitoclast with a hammer to break through the thin layer of bone. Then he twirled it to cut through the fibers. After pulling out the orbitoclast, the procedure was repeated on the other side. The transorbital lobotomy took 10 minutes or less. Because it didn't require drilling through the skull, it could be done by rendering the patient unconscious via electroconvulsive shock. It could also be done by people who weren’t even surgeons. Since most mental hospitals didn't have operating rooms or surgeons on staff, this new method made it easier for a patient to get the procedure. Eventually Freeman performed lobotomies as outpatient procedures in his office, in addition to doing them in mental hospitals and teaching other doctors how to do them. So how well did lobotomies work? It all depends on who you ask. Next, we'll look at the different outcomes of patients who had lobotomies over the years. Soul Surgery: Successes and Failures in Lobotomy Patients

In the United States, about 50,000 patients were lobotomized, most of them between 1949 and 1956. Dr. Freeman himself performed between 3,500 and 5,000 of them. He called lobotomies "soul surgery" and claimed that they could be used to treat not only schizophrenia, but depression, chronic pain and other mental and physical conditions. Freeman, and other doctors who performed lobotomies, believed that they could relieve suffering. In some cases, they did. Freeman first performed his transorbital lobotomy on Ellen Ionesco in 1946. She was described as "violently suicidal" by Angelene Forester, her daughter. After Ionesco's lobotomy, Forester says that "it was just peace [.] it was like turning a coin over. That quick. So whatever he did, he did something right." Patricia Moen, who was also suicidal, was lobotomized by Freeman in 1962. Afterward, Moen said that she "just started living again." Her husband Glenn was "delighted at the way it turned out." Not all patients were so happy with life after their lobotomies. Howard Dully was lobotomized by Freeman as a 12-year-old boy in 1960. He wasn't mentally ill; his stepmother wanted to change his personality, which she described as defiant. Dully wasn't told about the operation
until afterward. He states that "the surgery damaged me in many ways. But it didn't 'fix' me, or turn me into a robot. So my family put me into an institution." Dully claims that he always felt different, like "a freak" and "ashamed." He lived in institutions for 10 years and battled addictions until his 50s. One of Freeman's most famous failures was the sister of a president. In 1941, Rosemary Kennedy, the sister of John F. Kennedy, was lobotomized at the age of 23. Rosemary was described as a shy and easygoing child, but in her teenage years, she became rebellious and moody. A doctor suggested that a lobotomy could calm Rosemary down. At the time, Freeman had only performed about 60 lobotomies and hadn't yet created his transorbital technique, so he performed a prefrontal lobotomy. The operation did make Rosemary more manageable, because she was essentially left with the mental capacity of an infant. She couldn't speak intelligibly or control some bodily functions, and she stared into space for hours. Rosemary spent the rest of her life in an institution. Some researchers have claimed that she was mildly mentally retarded prior to her lobotomy, while others say that she had some form of mental illness. Publicly, Rosemary was described as mentally retarded. Her sister Eunice Kennedy Shriver later helped to found the Special Olympics in her honor. Other lobotomy patients also experienced negative results. Neurologist Dr. Elliot S. Valenstein has said of lobotomies, "There were some very unpleasant results, very tragic results and some excellent results and a lot in between." Ironically, the procedure couldn't cure schizophrenics. According to neurosurgeon Dr. Frank Vertosick, "Unlike depression and mania, which are disorders of mood, schizophrenia is a disorder of thought. And what a lobotomy alters is emotional state, not cognitive abilities." If the results varied so much, then why did lobotomies become the way to treat mental illness? The answer lies in the state of psychiatric care during the time that the lobotomy was popularized. Developed in the 1930s, electroconvulsive therapy involves passing electrical current through the brain. It is still used today to treat the severely mentally ill. Although it had come a long way from the days of simply restraining and locking away the mentally ill, psychiatric care in the 1930s was still very limited. There was essentially no treatment for schizophrenic patients, for example. Psychiatrists attempted to treat their symptoms by prescribing drugs like sedatives, which suppressed the patient's nervous system, and trying a number of different mind-body therapies. Schizophrenics received hydrotherapy in the form of hot or cold baths for hours at a time. There were also a few different types of shock therapy: insulin, Metrazol and electroconvulsive therapy (ECT). All of these therapies induced seizures in patients. Many psychiatrists claimed that these therapies worked by "shocking" patients out of their illness. Others believed that there was a connection between epilepsy and schizophrenia -- a patient who had the former, even if it was induced, couldn't have the latter.
These treatments didn't generally cure schizophrenics, depressives and others of their mental illness; most were in and out of hospitals or ultimately spent their entire lives inside them. In addition, hospitals in the United States were overcrowded -- by 1940, there were around 1 million patients and the population was growing by 80 percent per year. Conditions were also deteriorating due to a lack of funding during the Great Depression. Public hospitals were understaffed and patients were often left without any kind of treatment. People embraced the idea of a speedy, simple cure and were hopeful that surgery could provide it. Some psychiatrists were very upset at the idea that a surgery that destroyed healthy brain tissue could cure mental illness. Accepting psychosurgery also meant acknowledging that other forms of therapy, such as the growing field of psychoanalysis, may not work. Still, many psychiatrists and neurologists were intrigued, Dr. Walter Freeman among them. His championing of the surgery eventually included a traveling "lobotomobile," a customized van in which he demonstrated his technique to the press as well as doctors at mental hospitals. He liked to show off by entering both eye sockets at one time with two different orbitoclasts. Critics likened Freeman to an evangelist for the cause, while supporters claimed that getting a lobotomy was as safe and easy as getting a filling at the dentist. When Howard Dully received the records of the lobotomy performed on him as a child, he discovered that it had cost his parents less than $200. Lobotomies cleared overcrowded hospitals, and unlike other psychiatric care, it promised immediate results. However, the so-called "lobotomy revolution" lasted less than 20 years. Next, we'll look at how it fell out of favor and what's happening with psychosurgery today. In 1950, a drug named chlorpromazine (sold as Thorazine) was synthesized. This marked the beginning of the end for lobotomies as treatment for mental illness in the United States. Thorazine was the first in a series of antipsychotic drugs, and some have described it as the biggest single advance in the treatment of schizophrenia -- on par with what the discovery of penicillin did for the treatment of infectious diseases. Some criticism had to do with the relaxed criteria for lobotomies. They were given to criminals, in some cases against their will, in an attempt to "cure" them of their desire to commit crimes. Some battle-fatigued World War II veterans were lobotomized so they could free up space in the hospitals. When patients couldn't consent to the operation themselves, their family members did so, but sometimes the family member was more interested in getting rid of their problem than actually helping the patient. As more stories of abuse and disastrous results became public and antipsychotic drugs got widespread use, lobotomies were all but forgotten. Although the lobotomy has been banned in several countries, it's still performed in limited numbers in several countries today. Often it's used to treat epilepsy. Now known as NMD (neurosurgery for mental disorder), lobotomies are performed in two hospitals in Great Britain as a last resort to treat obsessive-compulsive disorder and severe depression. Those who support it still believe it can be beneficial when all other treatments have failed. Modified From: http://science.howstuffworks.com/life/inside-the-mind/human-brain/lobotomy.htm/printable